Effect of improved disease management strategies on hospital length of stay in the treatment of congestive heart failure

Meta-Analysis of Point-of-Care Lung Ultrasonography Versus Chest Radiography in Adults With Symptoms of Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is a primary cause of older adults presenting to the emergency department with acute dyspnea. Point-of-care lung ultrasound (LUS) has shown comparable or superior diagnostic accuracy in comparison with a chest x-ray (CXR) in patients presenting with symptoms of ADHF. The systematic review and meta-analysis aimed to elucidate the sensitivity and specificity of LUS in comparison with CXR for diagnosing ADHF and summarize the rapidly growing body of evidence in this domain. A total of 5 databases were searched through February 18, 2021, to identify observational studies that reported on the use of LUS compared with CXR in diagnosing ADHF in patients presenting with shortness of breath. Meta-analysis was conducted on the sensitivities and specificities of each diagnostic method. A total of 8 studies reporting on 2,787 patients were included in this meta-analysis. For patients presenting with signs and symptoms of ADHF, LUS was found to be more sensitive than CXR (91.8% vs 76.5%) and more specific than CXR (92.3% vs 87.0%) for the detection of cardiogenic pulmonary edema. In conclusion, LUS is more sensitive and specific than CXR in detecting pulmonary edema. This highlights the importance of sonographic B-lines, along with the accurate interpretation of clinical data, in the diagnosis of ADHF. In addition to its convenience, reduced costs, and reduced radiation exposure, LUS should be considered an effective alternative to CXR for evaluating patients with dyspnea in the setting of ADHF.

Obesity, brain natriuretic peptide levels and mortality in patients hospitalized with heart failure and preserved left ventricular systolic function

BACKGROUND

An inverse relationship between brain natriuretic peptide (BNP) levels and body mass index (BMI) has been described for patients with left ventricular (LV) systolic dysfunction. In this study, the association of BMI, BNP levels and mortality in patients hospitalized for heart failure with preserved LV systolic function (HFpLVF) was investigated.

METHODS

One hundred fifty consecutive patients (98% men) who were hospitalized with HFpLVF and had BNP levels measured on admission were analyzed. Patients were divided into categories of BMI: normal (BMI < 25 kg/m), overweight (BMI 25-29.9 kg/m) and obese (BMI ≥ 30 kg/m). Relevant clinical and echocardiographic characteristics and all-cause mortality were obtained through chart review.

RESULTS

BNP levels were significantly lower in obese (median = 227 pg/mL) and overweight (median = 396 pg/mL) patients compared with those with normal BMI (median = 608 pg/mL, P = 0.003). Higher BMI predicted BNP levels of <100 pg/mL. Compared with patients with normal BMI, overweight and obese patients had a significantly lower risk of total mortality, even after adjusting for other clinical characteristics, including log-transformed BNP levels, atrial fibrillation, the use of beta-blockers at discharge, age, hemoglobin levels and the presence of pulmonary congestion on admission. Higher BNP levels also independently predicted mortality.

CONCLUSIONS

An inverse relationship between BMI and BNP levels exists in patients hospitalized with HFpLVF. Higher BMI is associated with lower mortality, whereas higher BNP levels predict higher mortality in male patients with HFpLVF. These findings should be confirmed in a larger multicenter setting.

The effects of an advanced practice nurse-directed heart failure program

This study sought to determine if an inpatient heart failure program directed by an advanced practice nurse could affect length of hospital stay, mortality, readmission rates, and adherence to the recommended clinical regimen.

Testing the psychometric properties of the Chinese version of the heart failure learning needs inventory

OBJECTIVE

To translate the Heart Failure Learning Needs Inventory into Chinese and to evaluate its psychometric properties in the Chinese population with heart failure (HF).

METHODS

The study used a cross-sectional design. Instrument performance was measured on a convenience sample of 247 patients with HF recruited from the cardiac departments of 3 university-affiliated hospitals and repeated on 34 patients to examine the test-retest reliability.

RESULTS

One item of advanced directives was deleted from the Chinese version of the instrument because of its poor culture relevance. The Chinese version demonstrated acceptable internal consistency with a Cronbach's alpha of .96 for the total scale and .77 to .89 for the subscales. The item-to-total correlation ranging from .54 to .85 provided further evidence of the instrument's internal consistency. The content validity index was .86, indicating satisfactory content validity. The test-retest reliability was satisfactory with an intraclass correlation coefficient of .96 for the total scale and .61 to .91 for the subscales. There were no significant differences in the total scale and subscale scores over 10 days (P > .05). This finding further supported the stability of the instrument. Moreover, principle component analysis revealed 9 factors, explaining 60.89% of the variance. Means of the subscales were relatively lower than that of the western countries. Furthermore, the means of 2 subscales, general HF information and lifestyle modification, were different among patients with New York Heart Association classifications I and IV.

CONCLUSION

The Chinese version of the Heart Failure Learning Needs Inventory is a reliable and valid instrument to measure the learning needs of patients with HF in Mainland China.

Admission characteristics predicting longer length of stay among elderly patients hospitalized for decompensated heart failure

BACKGROUND

Acutely decompensated heart failure (HF) has become the leading cause of hospitalization for people aged 65 or older. Hospital length of stay (LOS) is a key determinant of higher hospitals costs. The aim of our study is to identify the admission characteristics that predict a longer LOS for elderly patients admitted for an acute exacerbation of HF.

METHODS

We prospectively evaluated 324 patients (65 years of age or older), who were consecutively admitted for decompensated HF to a tertiary teaching hospital. Variables present at the time of emergency room evaluation that could predict a longer hospital LOS were determined by comparing the characteristics of patients hospitalized for less than 4 days with those of patients needing a longer stay.

RESULTS

There were 191 women (59%) and 133 men in the study, with an average age of 78.6 years and a mean LOS of 7.1 days. Multivariate regression models identified two independent predictors of a hospital stay longer than four days: female gender (p=0.03, OR 1.645, 95% CI 1.047-2.584) and poorer NYHA functional class (p<0.01, OR 1.699, 95% CI 1.135-2.542).

CONCLUSION

In elderly patients admitted for decompensated HF, the female gender and a worse functional class at the time of admission were associated with a longer subsequent LOS.

Economic burden of heart failure: a summary of recent literature

OBJECTIVE

We reviewed literature published from 1995 to 2002 to highlight findings on the economic burden of heart failure (HF). Methods A key-word search of literature indexes for relevant citations identified 54 articles that were then summarized for findings on HF economics.

RESULTS

Results were described in terms of burden of illness, cost-effectiveness analysis, and resource utilization and costs. Hospitalization of the elderly is the driving force behind HF costs. Interventions that decrease the frequency of hospital admissions while maintaining clinical and patient reported outcomes are considered a high priority among decision makers and clinicians. Although the cost-effectiveness of therapy with beta-adrenergic blocking agents has been well established in the literature, the cost-effectiveness of hospital- or home-based HF management programs is still under debate. The issues of payer status and physician specialty impact on decreased hospital admission and cost have been inconclusive.

CONCLUSIONS

Any intervention capable of decreasing even a small fraction of adverse outcomes, most notably hospital admission and length of stay, could trigger significant cost savings in the management of HF. Public policy makers, together with clinicians identifying cost saving or cost-effective interventions in their practice, are expected to increase their efforts to evaluate the cost-effectiveness and outcomes of medical and pharmacologic interventions in HF.

What can a pilot congestive heart failure disease management program tell us about likely return on investment?: A case study from a program offered to federal employees

In 1999, the Blue Cross and Blue Shield Federal Employee Program (FEP) implemented a pilot disease management program to manage congestive heart failure (CHF) among members. The purpose of this project was to estimate the financial return on investment in the pilot CHF program, prior to a full program rollout. A cohort of 457 participants from the state of Maryland was matched to a cohort of 803 nonparticipants from a neighboring state where the CHF program was not offered. Each cohort was followed for 12 months before the program began and 12 months afterward. The outcome measures of primary interest were the differences over time in medical care expenditures paid by FEP and by all payers. Independent variables included indicators of program participation, type of heart disease, comorbidity measures, and demographics. From the perspective of the funding organization (FEP), the estimated return on investment for the pilot CHF disease management program was a savings of $1.08 in medical expenditure for every dollar spent on the program. Adding savings to other payers as well, the return on investment was a savings of $1.15 in medical expenditures per dollar spent on the program. The amount of savings depended upon CHF risk levels. The value of a pilot initiative and evaluation is that lessons for larger-scale efforts can be learned prior to full-scale rollout.

A matched-cohort study of health services utilization outcomes for a heart failure disease management program

Chronic disease is the leading cause of illness, disability, and death in the United States, affecting nearly 100 million Americans. Heart failure alone affects nearly 4.9 million Americans, with another 550,000 newly diagnosed cases each year. The aim of this study was to investigate the program effects of a heart failure care support program. A two-group cohort study matching on propensity scores was used to investigate 277 heart failure care support program participants and corresponding matched non-participants. Measures used were rates of hospitalizations, emergency department visits, physician office visits, and heart failure-related prescription drug use and procedures. Relative to the matched control group, program participants experienced 26.3% (p = 0.023) fewer inpatient admissions, 37.9% (p = 0.018) inpatient bed days, 33.3% (p = 0.059) more beta blocker use, 76.7% (p = 0.048) more alpha blocker use, 22.2% (p = 0.006) more lipid panels, 13.4% (p = 0.019) more electrocardiographies, 50.0% (p = 0.008) fewer cardiac catheterizations, and 94.6% (p = 0.014) more pneumonia vaccinations. The current study employs a propensity score matching methodology to select a subset of comparison patients most comparable to treatment patients, and documents the beneficial health services outcomes of participation in a heart failure care support program.

A Matched-Cohort Study of Health Services Utilization and Financial Outcomes for a Heart Failure Disease-Management Program in Elderly Patients

OBJECTIVES

To investigate the utilization and financial outcomes of a telephonic nursing disease-management program for elderly patients with heart failure.

DESIGN

A 1-year concurrent matched-cohort study employing propensity score matching.

SETTING

Medicare+Choice recipients residing in Ohio, Kentucky, and Indiana.

PARTICIPANTS

A total of 533 program participants aged 65 and older matched to nonparticipants.

INTERVENTION

Disease-management heart failure program employing a structured, evidence-based, telephonic nursing intervention designed to provide patient education, counseling, and monitoring services.

MEASUREMENTS

Medical service utilization, including hospitalizations, emergency department visits, medical doctor visits, skilled nursing facility (SNF) days, selected clinical indicators, and financial effect.

RESULTS

The intervention group had considerably and significantly lower rates of acute service utilization than the control group, including 23% fewer hospitalizations, 26% fewer inpatient bed days, 22% fewer emergency department visits, 44% fewer heart failure hospitalizations, 70% fewer 30-day readmissions, and 45% fewer SNF bed days. Claims costs were 1,792 dollars per person lower in the intervention group than in the control group (inclusive of intervention costs), and the return on investment was calculated to be 2.31.

CONCLUSION

The study demonstrates that a commercially delivered heart failure disease-management program significantly reduced hospitalizations, emergency department visits, and SNF days. The intervention group had 17% lower costs than the control group; when intervention costs were included, the intervention group had 10% lower costs.

Decompensated heart failure: symptoms, patterns of onset, and contributing factors

PURPOSE

To examine the time course, contributing factors, and patient responses to decompensated heart failure.

METHODS

We studied consecutive patients admitted to a public general hospital with a diagnosis of heart failure. Using a timeline follow-back technique, a nurse interviewer administered a questionnaire shortly after admission, exploring knowledge of a heart failure diagnosis, the symptoms and time course of decompensation, and patient responses to worsening symptoms.

RESULTS

Of 87 patients, 83 (95%) consented to be interviewed. Only 49 (59%) were aware of the diagnosis of heart failure. Symptoms associated with decompensation included dyspnea in 81 patients (98%), edema in 64 patients (77%), and weight gain in 34 patients (41%). Onset of worsening of these symptoms was noted a mean (+/- SD) of 12.4 +/-1.4 days before admission for edema, 11.3 +/-1.6 days for weight gain, and 8.4 +/- 0.9 days for dyspnea. Forty-two patients (57%) reported missing or skipping medication because of various factors, particularly missed outpatient appointments.

CONCLUSION

Using a timeline follow-back interview, we identified a period of days to weeks between the onset of worsening symptoms and hospital admission for heart failure decompensation. This pattern suggests that there is a time window between symptom exacerbation and admission during which earlier access and intervention might prevent hospitalization in these patients. Medication lapses continue to be an important preventable cause of decompensation leading to admission.

Underutilisation of ACE inhibitors in patients with congestive heart failure

Congestive heart failure (CHF) is associated with substantial morbidity and mortality, and is the only major cardiovascular disease increasing in prevalence. Despite abundant evidence to support their efficacy and cost-effectiveness, angiotensin-converting enzyme (ACE) inhibitors are sub-optimally used in patients with CHF. This paper reviews the evidence for the sub-optimal use of ACE inhibitors in patients with CHF, the factors contributing to this, and its implications for health systems. A systematic review of all articles assessing practice patterns (specifically the use of ACE inhibitors in CHF) identified by MEDLINE, search of bibliographies, and contact with content experts was undertaken. 37 studies have documented the use of ACE inhibitors in patients with CHF. Studies assessing use among all patients with CHF document 33% to 67% (median 51%) of all patients discharged from hospital and 10% to 36% (median 26%) of community dwelling patients were prescribed ACE inhibitors. Rates of ACE inhibitor use range from 43% to 90% (median of 71%) amongst those discharged from hospital having known systolic dysfunction, and from 67% to 95% (median of 86%) for those monitored in specialty clinics. Moreover, the dosages used in the 'real world' are substantially lower than those proven efficacious in randomised, controlled trials, with evaluations reporting only a minority of patients achieving target doses and/or an overall mean dose achieved to be less than one-half of the target dose. Factors predicting the use and optimal dose administration of ACE inhibitors are identified, and include variables relating to the setting (previous hospitalisation, specialty clinic follow-up), the physician (cardiology specialty versus family practitioner or general internist, board certification), the patient (increased severity of symptoms, male, younger), and the drug (lower frequency of administration). In light of the substantial evidence for reductions in morbidity and mortality, clearly, the prescription of ACE inhibitors is sub-optimal. Wide variability in ACE inhibitor use is noted, with higher rates consistently reported among patients having systolic dysfunction confirmed by an objective assessment--an apparent minority of the those having CHF. Optimisation of the prescription of proven efficacious therapies has the potential to confer a substantial reduction in the total cost of care for patients with CHF by reducing hospitalisations and lengths of hospital stays. It is likely that only multifaceted programs targeted toward the population at large will yield benefits to the healthcare system, given the widespread nature of the sub-optimal prescription of therapies proven effective in the management of patients with CHF.

APN spells success for a heart failure program

Review the relationship between advanced practice nurse-directed heart failure programs and patient length of stay, mortality, re-admission rate, and adherence to recommended clinical regimens.

Should cardiopulmonary resuscitation be performed on patients with heart failure? The role of the patient in the decision-making process

OBJECTIVES

There is an ongoing debate about patients' involvement in the decision of whether or not to start, cardiopulmonary resuscitation (CPR) in the case of cardiac arrest. The objective here is to analyse on what grounds patients with heart failure, who run a relatively high risk of suffering cardiac arrest, form their attitudes towards CPR and to what extent they want to be involved in making decisions concerning CPR.

DESIGN

This study employs a combined qualitative and quantitative interview concerning patients' knowledge about CPR, their experiences and preferences regarding involvement in making decisions concerning CPR, and their willingness to undergo CPR.

SETTING

The study was performed at the Department of Cardiology, Sahlgrens University Hospital, Gothenburg.

SUBJECTS

The subjects involved were 40 patients with various stages of chronic heart failure.

RESULTS

Many of the interviewees lacked fundamental knowledge of CPR. The majority of the patients opted for CPR no matter how small their chances of survival were. The issue had not earlier engaged their thoughts, even less been discussed with physicians. The patients relied on the physician's ability to judge if CPR was to be regarded as a potentially beneficial intervention or as an unmotivated one. Nevertheless, the patients welcomed the opportunity to take part in the decision-making process.

CONCLUSION

In order to make ethically justified decisions, physicians should consider bringing up the question of CPR with patients suffering from heart failure at the point in time where the progressive disease gives rise to more severe symptoms, corresponding to NYHA classes IIIb-IV. In earlier stages of the disease, one can assume that the patient will opt for CPR unless he or she demonstrates a negative attitude towards life.